Sample: Self-Assessment Best Practices

Management Team Meeting Notes Clinic Capacity Assessment 1) Mission: Rating Moderate Level Comments: Consider modification due to changing health care environment to expand populations served. Do this incrementally. Diversify patients. Sees expansion to two floor model in May as an opportunity to diversify patients but might have some implication for the mission statement Add something to the effect of considering the health care needs of our surrounding community Competition issue comes into play. Some of our proposals are funded specifically because of our niche of serving the API communities. Review the needs of smaller communities such as Armenians and South Asians Dont assume that the Spanish speaking populations are met just because there are clinics serving them. The numbers of Spanish speaking patients are really large in Los Angeles. 2) Vision: Rating basic to Moderate Level Comments: We plan well with vision in mind, but need to integrate and communicate vision into everything we do with line staff. They said they recognize what were doing, but dont connect it to the vision statement. 3) Strategic Plan: Rating High Level Comments: Need to communicate to staff how the vision links wish strategic plan. We do well with the mission statement but need more work for vision statement with line staff. 4) Assessment of Community Needs & Clinic Environment: Rating Basic to Moderate Comments: We do a good job in incorporating the environmental information and data from some areas but not all. Form a community advisory board, but exercise caution. It could be contentious and become polarized. We need to continue to strengthen our evaluation to measure outcomes. Need for focus groups on all target populations re: strategic plan.

Need to define what community needs assessment that the agency can reasonable do for planning purpose. Public health is defined very broadly. Who are people in the communities that are not accessing the services? Those are who we need to know about. Advisory board a good idea. Could be a link to the communities; key informants. 5) Partnerships and Alliance Development: Rating Moderate to High Comments: EDs relationships/networking with county and Federal Government is good Not sure if we have sufficient mutually beneficial relationships (examples: Hospital XX and other hospitals.) Need for stronger relationships for referrals. We have good financial relationships with funders Need to improve on partnerships of other types Partnership development takes a lot of resources and time Relationship and partnership building will pay-off in the long run. 6) Board Governance: Rating Moderate Comments: More Board training is required due to new consumer board members recently on board Need for stronger, more stable consumer members. (Some have not been able to participate at meetings due to illness.) Ned for more active committees. Staff want to see the Board being more proactive 7) Board Fundraising: Rating Basic to Moderate Comments: Enthusiastic members Concern about consumer members ability to raise funds New members have contacts Maybe establish levels of contributions for Board members 8) Management Team Composition: Rating High Comments: Everyone makes the commitment to fully attend and follow up Everyone from all major departments including Medical Director actively participates in Management Team meetings 9) Management Team Decision-Making: Rating Moderate to High

Comments: High in a sense that:

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Management team all understands the clinics direction, goals and objectives. Management team understands the progress we are making towards goals and objectives The management team can and does make key decisions in EDs absence based on the direction, goals and policies and procedures, and cc to her later.

Need to work on:

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Continued management training for finances, personnel, evaluation, etc. Better communication between staff who plan, implement and monitor programs and contracts. Create easier access to program/service information and data, centralize forms, documents, policies and procedures, proposals, etc. Need to build a strong HR department, but this is being worked on right now.

10) Bottom Line: Rating High 11) Cash Position: Rating High Comments: Need a financial plan over the next five to ten years We can have such plan, but it all depends on our strategic plan that we develop every threeyear. With a volatile health care environment, is it useful to have a 10-year plan? The fiscal department may need people who are more proactive and involved in decisionmaking. Need to look at skill to become stronger 12) Diversity of Revenue Sources: Rating Basic to Moderate Level Comments: Clinics overall portfolio is diverse. About 98% of our entire budget used to be government in funds 1997. Now it is about 60%. Within the government funds, they are equally distributed among the state, federal and count and city sources. Now we have more patient revenues and private foundation and donors to make up the remaining 40%. However, the patient service payor source continues to need diversity in concerned about when PPP funding ends. 13) Fund Development Strategy and Activities: Rating Basic to Moderate Comments: Aim at diversifying fundraising activities. Either more events or donor cultivation type of events ED feels comfortable with the way that the current fundraising operation is set up. Events take a lot of resources and time.

Need for more discretionary funds but what do you need the funds for? We need to define the needs first, and then set up goals and work toward them. Discretionary funds raised could go toward staff benefits/ COLAs Discretionary funds could be used to keep staff on board when grant funding runs out.

14) Fund Development Staff, Budget & Skills: Rating Moderate Comments: Suggested further development of fund development staff department. Wants to be able to filter proposals, data, etc. through one department Suggested development staff works with Health Education department to write proposals, and monitor evaluation. Suggested that a fund development assistant would be helpful, but is okay with the way things are now We can start by centralizing data and creating a data bank for proposals. We can also centralize information about who is writing what proposal so we dont duplicate our efforts Emphasized team approach to proposal writing. Managers and staff working directly in programs bring the best ideas to proposals.